final exam short case

This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This elog book reflect s my patients centered online portfolio and your valuable inputs on the comments is welcome. 
 Chief complaint 
A 65year old male patient of resident  farmer by occupation came to opd with a complaint of
Cough with Expectoration and right knee pain from 1 year , lower back ache, neck pain, and burning sensation of feet from 6 months. 
History of present illness 
Patient was apparently Assymtomatic since 1year then he developed cough with Expectoration (thick, whitish, non blood tinged, odour less sputum). 
No History of fever, cold, shortness of breath, chestpain. 
History of lower back ache radiating to lower limb since 6 months  not associated with tingling sensation. 
History of neck pain radiating to upper limb since 6 months not associated with tingling sensation. 
History of burning sensation of both feet since 6 months not associated with tingling sensation, numbness. 
History of right knee pain since 1yr which is increased with exertion & associated with crepitus. 
Also has history of nocturia, dribbling of urine since 6 months, not associated with Polyuria, polydypsia, polyphagia. 
History of past illness 
No H/o trauma 
K/c/o Hypertension since 6 months and he is on regular medication of Tab TELMISARTAN 40mg.
No H/o Dm, epilepsy, Tb, asthma. 
Family History
No significant family history. 
Personal History
Diet - mixed 
Appetite - normal
Bowel and bladder movements - regular 
Micturation - Abnormal (Nocturia with dribbling of urine since 6 months). 
Allergies- no allergies 
Addictions - drink toddy daily 2 litres 
                    - beedi smoker daily 10 per day
Physical Examination 

General
Patient is conscious, coherent, cooperative and well oriented to time and place. 
Patient is moderately built and well nourished. 
Pallor - absent
Icterus - absent 
Cyanosis- absent
Clubbing-absent 
Lymphadenopathy-absent 
Edema - absent

Vitals
Temperature - Afebrile
Pulse rate - 76bpm
Respiratory rate - 16 cycles per minute
Bp - 170/90 mmhg
Spo2 - 98%
Systemic examination

Cvs 
No thrills 
No murmurs 
S1 and S2 are heard

Respiratory system 
Inspection-     I have taken patient consent and examined the patient in sitting position. 
Upper respiratory tract- oral cavity, nose & orophayrnx is normal . 
Chest is  bilaterally symmetrical & elliptical in shape 
Position of trachea is central. 
Respiratory movements appear equal on both sides & it is Abdominothoracic type. 
No scars, veins, sinuses, visible pulsations.
 
Palpation- 
All inspectory findings are confirmed 
No local rise of temperature
No tenderness 
Trachea is in Central position

Percussion-

                                    Right              . Left

Supraclavicular Resonant.                   R

Infraclavicular.  .         R                         R

Mammary. .                 R                        R

Axillary.                         R                      R

Infra axillary.                  R                     R

Suprascapular.               R                     R

Interscapular.              R                      R

Infrascapular              R                        R

Auscultation-

                                 Right.                 Left

Supraclavicular.  NVBS                  NVBS
Infraclavicular.    NVBS                  NVBS

Mammary.           NVBS                  NVBS

Axillary.               . NVBS                NVBS

Infra axillary.         NVBS               NVBS

Suprascapular.       NVBS             NVBS

Interscapular.         NVBS             NVBS

Infrascapular           NVBS    .       NVBS

Abdomen 
Shape of the abdomen - normal 
Tenderness- no 
Palpable mass - no 
Hernial orifices- normal 
Liver & spleen are not palpable
Bowel movements - present 
No dilated veins, scars, sinuses. 

Cns 
Patient is conscious, coherent, cooperative and well oriented to time & place 
Speech - normal 
No signs of meningitis
Memory intact 
Motor and sensory system - normal 
No kerning sign 


Provisional diagnosis 
Cough under evaluation 
Lower back ache under evaluation
Ankylosing spondylosis 
Treatment
Tab ultracet -37. 5 mg tramadol HCL
                      -325mg acetaminophen
Tab pregabalin 75mg 
Syp Ascoryl 10ml 
Tab Telma 40mg 
Tab pantop 40mg 
Tab shelcal 500mg


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